Northeast Florida

NOrtheast florida

Camp Cadet Application

P.O. Box 476

Green Cove Springs, Florida32043

Telephone: (904) 701-3014

ELIGIBILITY CRITERIA FOR CAMP CADET

Applicants must be no younger than 12 and no older than 15 years of age on the first day of Camp Cadet and must reside within Northeast Florida.

Applicants must be willing to participate in a variety of physical fitness activities and abide by military discipline. Additionally all applicants must arrive at Camp Cadet with an appropriate haircut. For boys, this means no hair extending below the eyebrows in the front, below the ears on the sides, and it cannot touch the collar of their shirt. In other words, a military style haircut. For girls there are no specific requirements other than they must be able to pull their hair back in either a ponytail or use similar means to keep the hair out of their face. The hair must also be able to fit under a baseball cap, although the ponytail may protrude from the back.

This application must be submitted no later than April 6, 2018. The application must be accompanied with the 500 word essay (What leadership means to him/her), a recent physical (can use the 2017 -2018 school year physical) and the medical addendum (to be provided at a later time). Submit this application to “Northeast Florida Camp Cadet” at the address listed above. Any application received after the April 6, 2018 deadline may not be considered.

Final selection of the Camp Cadet applicants will be made by the Northeast Florida Camp Cadet, Inc. board members.

Applicants MUSTarrive on time at Camp Cadet for registration and orientation. Camp Cadet is being held at North Fork Leadership Center and registration is scheduled to begin on Sunday, June 10th2018 at 2:30 PM. Applicants who arrive late on the day of registration may be asked to leave without advanced notice. Graduation will take place on Saturday, June 16that 11:00 AM.

Scan the QR Code with your smart device to go to the Camp Cadet Web Page

NOrtheast florida

Camp Cadet

P.O. Box 476

Green Cove Springs, Florida 32043

Telephone: (904) 701-3014

Dear Parents,

The Northeast Florida Camp Cadet would like to share some vital information that will prove helpful for you and your child should they be selected to participate in the Camp Cadet program. We provide this information so that you, the parents, can be as fully informed as possible to assist your child in this exciting opportunity.

If your child is selected to participate in the program it is imperative that you provide everything on the camp list provided. The list is comprehensive and will serve your child well for the week. Avoid bringing any items not listed as room is limited for the cadets. Please pack your child’s items in as small a suitcase or duffle bag as possible, as your child will be carrying their luggage to the bus and to their bunking areas. Large suitcases and duffle bags can be quite heavy and difficult to carry for the smaller children.

Should your child become injured or is dismissed for disciplinary reasons a prompt pick up is mandatory. Non-emergency medical attention must be provided by the parent/guardian as quickly as possible.

Cadets dismissed due to disciplinary reasons have a tendency to drain camp resources and manpower creating the need for immediate removal by a parent/guardian. This will ensure the rest of the cadets still participating will not experience a disruption in their activities. In addition,the parents of any cadet dismissed for disciplinary reasons or for a non-disclosed medical condition will be assessed a $250 fee to cover the loss associated with such action. This does not apply to cadets who become injured during participation.

Dismissals due to disciplinary reasons or a non-disclosed medical condition will be final and the cadet will not be able to re-apply for another camp.

Your child will need to have a physical exam conducted to participate in Camp Cadet. Please understand that this is a physically demanding camp, and your child must be physically able to participate in the camp’s activities. If any condition that would hinder full participation arises between the time of the physical exam and the start of camp or any medical condition that was not disclosed to anyone (including a physician) prior to camp must be disclosed to the staff prior to the first day of camp. If a condition is not disclosed prior to camp the cadet risks being dismissed.

A photo of each cadet will be taken during registration for the safety and welfare of each cadet.

Please consider this guide carefully. Camp Cadet is committed to providing a safe, nurturing and somewhat demanding environment in which the participants (and staff) can learn and grow together. It is our sincere hope that we can work together for the betterment of our kids. Please do not hesitate to contact any of the staff members if you have any questions or need any further clarifications.

Thank you,

Kimberly Robinson

Northeast Florida Camp Cadet Director

northeast florida camp cadet application
Applicant Information
Name:Enter text. / Phone: Enter text.
Address: Enter text. / City:Enter text. / State: Enter text. / County:Enter text.
Date of birth:Enter text. / Age:Enter text. / Sex:Enter text. / Current grade:Enter text.
Shirt size: ☐XS ☐S ☐M ☐L ☐XL ☐XXL
(NOTE: SHIRT SIZES LISTED ARE ADULT MALE SIZES) / Short size: ☐XS ☐S ☐M ☐L ☐XL ☐XXL
(NOTE: SHIRT SIZES LISTED ARE ADULT MALE SIZES)
Applicant’s swimming ability: ☐ cannot swim ☐ beginner level ☐intermediate level ☐advanced level
School Information
School currently attending:Enter text.
Address:Enter text. / City:Enter text. / State:Enter text. / County:Enter text.
School conduct: ☐Excellent ☐Good ☐Fair ☐Poor **MUST BE SIGNED BY GUIDANCE COUNSELOR OR ADMINISTRATOR**
Signature: / Printed name:
Title: / Phone number:
PARENTS / GUARDIANS INFORMATION
Name:Enter text. / Email:Enter text.
Address:Enter text. / City:Enter text. / State:Enter text. / Relationship:Enter text.
Work phone number:Enter text. / Cell phone number:Enter text.
Name:Enter text. / Email:Enter text.
Address:Enter text. / City: Enter text. / State:Enter text. / Relationship:Enter text.
Work phone number:Enter text. / Cell phone number:Enter text.
EMERGENCY CONTACT (MUST BE A RELATIVE)
Name:Enter text. / Relationship to Cadet:Enter text.
Address:Enter text. / City:Enter text. / State:Enter text.
Work phone number: Enter text. / Cell phone number:Enter text.
Health insurance information
Name of insurance:Enter text. / Phone number:Enter text.
Address:Enter text. / City:Enter text. / State:Enter text.
Name of Insured:Enter text. / Policy number:Enter text.
Required items to be turned in
☐ Completed application ☐ 500 word essay on what Teamwork and Discipline means to the applicant
☐ Recent physical exam (can use the 2017 – 2018 school year physical)
Signatures
I hereby waive and release any and all rights and claims for damages I may have against any and all individuals associated with Northeast Florida Camp Cadet, Inc., North Fork Leadership Center, and the state of Florida while my child attends Camp Cadet for any and all injuries suffered by him/her at said camp. I attest and verify that my child is physically fit and able to attend camp. I also understand that parents of cadets dismissed for disciplinary issues or undisclosed medical reasons will be assessed a $250 fee.
Parent Signature: / Date:
Applicant Signature: / Date:

NOrtheast florida

Camp Cadet

P.O. Box 476

Green Cove Springs, Florida 32043

Telephone: (904) 701-3014

PARENTAL PERMISSION AND RESPONSIBILITY

I understand that Northeast Florida Camp Cadet, Inc. may accept my child to attend camp on the basis that I/WE have agreed to assume all risks arising from participation in said camp. I/WE, the Parent/Guardian of Click here to enter text., consent to his/her participation in this program and assume all risks and claims of damage of any nature or kind which my child could receive by reason of accident or injury while attending camp. The camp staff and/or local hospital have my permission to treat the above child in the event of an emergency.

I/WE am/are interested in the policies, regulations, and aims of the activities of the Northeast Florida Camp Cadet program. I/WE will talk to MY/OUR child prior to camp and encourage HIM/HER to take part in all activities, and to cooperate with the camp staff and guest speakers. In the event of any of the camp activities are planned away from the camp area, my child has permission to take part in such activities.

I/WE also understand that if MY/OUR child’s behavior violates any of the camp’s rules or intimidates other campers, the camp counselors reserve the right to take appropriate disciplinary actions to address the situation. Cadets who violate any of the camps rules or regulations, or who display inappropriate behavior or attitude may be dismissed from the camp at any time. Transportation to and from the camp is solely MY/OUR responsibility.

Name of applicant:Click here to enter text.

Signature of Parent/Guardian:______

Date:Click here to enter a date.

NOrtheast florida

Camp Cadet

P.O. Box 476

Green Cove Springs, Florida 32043

Telephone: (904) 701-3014

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

Patient’s name:Click here to enter text.

Date of birth:Click here to enter a date.

Social Security number:Click here to enter text.

Address:Click here to enter text.

I request and authorize Northeast Florida Camp Cadet Inc. to release healthcare information of the patient named above to Emergency Medical Services or as may needed by Emergency Medical personnel who may be deemed necessary by Camp Officials or any Camp Counselor or Instructor.

This request and authorization applies to:

_X_All medical information disclosed by the parent or the minor child as part of the Camp application procedure or as may be learned by Camp Officials from the child during camp
_X_All hospital records (including nurse records and progress notes / _X_Dental records
_X_Transcribed hospital records / ___ Physical therapy records
_X_ Medical records needed for continuity / _X_Emergency and urgency care notes
_X_ Most recent five-year history / ___ Billing statements
___ Laboratory reports / ___ All reports and testing
_X_Pathology reports / ___ All self-patient reporting documents
___ X-Rays, MRIs, CT Scans, and Images / ___ Sensitive materials (see below)
_X_All diagnostic reports / ___ All of the above
___ Clinical office chart notes / ___ Other. If other, specify information

This information, if requested, is being requested for the purpose of patient care only while the patient is attending the Camp Cadet summer camp session.

Please release records for the dates of: Any and all

Note on “sensitive materials”: sensitive materials may include, but is not limited to, any health care information relating to testing/diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. If “sensitive materials” has been checked, you are specifically authorized to release all health care information relating to such acquired information, diagnosis, testing, or treatment.

I have read and understand the following:

This authorization is valid for 90 days after the date it is signed.
This authorization is revocable at any time by the patient.
Although prohibited, it is possible that my PHI may be re-disclosed as a result of the patient’s litigation by the facility receiving my records, therefore, the provider has not responsibility or liability as a result of the re-disclosure, and such information would no longer be protected by the HIPAA privacy rule.

______

Signature of patient/patient’s authorized representativeDate signed

______

Relationship or status if signed by anyone other than patient

(parent, legal guardian, personal representative, etc.)

NOrtheast florida

Camp Cadet

P.O. Box 476

Green Cove Springs, Florida 32043

Telephone: (904) 701-3014

MEDICATION ASSESSMENT

Child’s name:Click here to enter text.

Parents please fill this form out and return along with physical evaluation. Be as accurate as possible to ensure safe administration of medications and allow camp staff to effectively plan ahead.

Does your child have any medication or food allergies? ☐ Yes ☐ No

If you answered “yes” above, please indicate to what, and his/her reaction is to the food allergy. If your child requires an epi-pen for an allergy, please make sure to include this beside the medication and or food allergy.

Click here to enter text.

Does your child currently take any prescribed medications? ☐ Yes ☐ No

If you answered “yes” above, please indicate which medications below, including dosage and frequency of use:

Click here to enter text.

Does your child currently take any over the counter medications on a regular basis? ☐ Yes ☐ No

If you answered “yes” above, please indicate which over the counter medications used:

Click here to enter text.

NOrtheast florida

Camp Cadet

P.O. Box 476

Green Cove Springs, Florida 32043

Telephone: (904) 701-3014

PHOTO / VIDEO RELEASE

For, and in consideration of, a copy of the photography used, the undersigned, with intent to be legally bound, does herby consent to the use and appropriation of his/her likeness in any Northeast Florida Camp Cadet, Inc. broadcast, publication, demonstration, or display of photographs and or video/film recording of Northeast Florida Camp Cadet, Inc. (hereinafter referred to as “Camp Cadet”). The undersigned recognizes that his/her likeness may be used in publications, periodicals, advertisements, promotional materials, commercials, or video presentations for dissemination to the general public. Without limitation or reservation, and with an understanding of the special precautions undertaken by Camp Cadet to ensure confidentiality, I knowingly, intentionally and voluntarily, and for my heirs and administrators and assigns, do, generally release Camp Cadet, its directors, officers, agents, employees, and members from any or all liability of every nature for the use of appropriation of my name or likeness. I further waive any and all claims or causes of action or claims including, but not to be limited to, defamation, false-light privacy, invasion of privacy, commercial misappropriation, and disclosure of private facts. I hereby state that I understand the content and effect of this release and intending to be legally bound hereby, sign and seal as follows:

Parent/Legal guardianprinted name: / Cadet printed name:
Signature: / (SEAL) / Signature: / (SEAL)
Address: / Address:
Phone number: / Phone number: